The Decision

This is the second post in a three-part series detailing my journey recovering from reconstructive knee surgery. In these long-form accounts I will dive into the genesis of my injury, the arduous process leading up to and recovering from surgery, and the grueling rehabilitation. This second post describes the decision-making process leading up to my surgery.

April 6th, 2015

Four days after my injury, I found myself in the crowded waiting room of Manhattan Orthopedic on the Upper East Side. What started out as an early morning 8:00AM appointment ended up turning up into an all-day affair filled with multiple doctor visits and hot dates with x-ray and MRI machines.

The morning started with complications right off the bat. I had switched jobs less than a month before my injury, so the insurance plan I had selected had not been activated yet. My first couple hours at the hospital were spent juggling phone calls with the receptionist at the clinic, my insurance company, and HR department at my job. Luckily I was a referred by a Village Lion who used to work at the clinic, so one of the doctors was able to get the process moving and get me to an x-ray machine while everything was being sorted out.

After my x-ray I sat back in the waiting room, which was super crowded on a Monday morning. There were plenty of sports related pictures around the office, which included several official New York Jets team pictures, a signed Mark Sanchez photograph thanking his doctor, and an autographed USA Eagles rugby jersey. However the wide range of clientele definitely stood out to me. There were a few young people such as myself who were there to treat athletic injuries, but also a fair share of elderly folks who were clearly there for non-sports related reasons. I didn’t think much of this at first, but this would become somewhat of a factor later on.

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This signed USA Eagles national team jersey was staring right at me during my time in the waiting room. Although there was a wide-range of patients, it reassured me that I was in good hands with experienced doctors who knew my sport.

I was finally called in to meet with Dr. M (for privacy, I will refer to the doctors I met with by using their initial). He had a rugby background, and was the doctor responsible for expediting the process for me while I dealt with my insurance issues. I told him the entire story of my knee injury,  and he performed a brief manual examination. After a review of my x-ray, he said I most likely tore my medial patellofemoral ligament, had potentially broken my kneecap, and because of the damage to my cartilage I would probably need a knee replacement by the time I was 50 or 60. While a part of me expected to hear torn ligament, I was floored by what he followed that up with. A knee replacement?!?! Broken kneecap? What the hell is the medial patellofemoral ligament?

At 27, I did NOT need to be hearing knee replacement, and basically told him that. He tried to reassure me by mentioning he would also need one down the line, and when you play competitive sports long enough it tends to happen. His sentiment was while it certainly sucks, technology is advancing at such a fast pace that these operations will only get easier in time. Plus, I should just focus on fixing this injury first.

I then was ushered across the hall to visit with Dr. H, who would be the doctor performing my surgery should I elect to have surgery with this group. Dr. H was extremely friendly, and you can tell he had been around the block a zillion times. He was less extreme with his prognosis, but also informative at this same time. While he recommended I receive an MRI immediately, he was pretty certain I did tear my MPFL. He wasn’t sure about the broken kneecap part, and wanted to wait and see the MRI results before  commenting any further. So I hobbled down the street to Lenox Hill Radiology, which was also a zoo this Monday. The MRI took a half an hour, and I’m pretty sure I dozed off for most of it. But with my x-ray and MRI checked off the list, I thought I had all of the information required for me to find out the full extent of my knee injury. It turns out I was mistaken.

A week or so later I was back in Dr. H’s office, and he confirmed the MPFL tear. However he also said what initially looked like broken kneecap pieces was actually my cartilage. He explained that because my injury persisted for so long, the extreme movement of my knee shifting laterally was tearing at the cartilage underneath my kneecap. He said this can be fixed several ways, some of which are more common than others. But I’ll pause right now to explain as best I can the meaning of these body parts and acronyms.

The medial patellofemoral ligament is a broad structure located on the inside of the knee joint that helps keep the kneecap centered along the front of the knee, ensuring that it tracks properly when your knee moves. It connects the kneecap (patella) to the thigh bone (femur). The primary purpose of the MPFL is to provide stability to the kneecap, as it provides restraint to any movement toward the outside of the knee. It also helps keep the kneecap in position as the knee bends and straightens.

Knee Image_MPFL
Source: http://noyeskneeinstitute.com/unstable-kneecap/

To repair most ligaments including the MPFL, the surgeon uses a graft to replace the damaged ligament. Depending on the injury, you are given the choice between an allograft or an autograft. An allograft uses a ligament harvested from a cadaver to replace your own, while an autograft takes a healthy piece of your body, usually a tendon from your patella or hamstring, to make the repair.

Dr. H seemed confident that I would make a quicker recovery with the allograft option. Since the MPFL was a relatively smaller ligament than an ACL, he subscribed to the school of thought that repairing it with a cadaver would be fine. The surgery would be outpatient, meaning I would be released the day of the operation. Recovery with proper rehabilitation would be three to four months, and most-likely I would be able to play rugby again in about six months or so. He explained he performed the same procedure on several players currently in the NFL, and they were doing just fine.

Initially I was relieved to hear this news. Although I had never been through a reconstructive knee surgery before, from afar I had always held the belief that you should do as little damage as possible to your body. With an autograft, the surgeon would essentially be creating an injury to a healthy body part in order to repair my damaged ligament, which I was hesitant to consider. Not only was I worried about causing unnecessary damage to my body, but I assumed the additional element to this procedure would prolong the time it would take to recover.

On the other hand, did I really want another person’s body part inside me? The fact that it would be coming from a dead body didn’t concern me too much, rather it was the fact I would have no control over the health history of whoever’s body part I was inheriting. Having no knowledge of this person’s age, genetics, lifestyle, or athletic history was troublesome to me. While I was confident that modern science has pretty much perfected the art of screening cadavers and selecting the healthiest pieces possible, it was nevertheless unsettling.

There was also my damaged cartilage, which would have to be fixed as well. This was the source of most of my pain, and Dr. H confirmed Dr. M’s assessment that the damage done here was definitely a long-term concern. This could be remedied by an arthroscopic cleaning, where the surgeon would trim the damaged cartilage. This is a fairly standard procedure for athletes, however each time it occurs you are left with less and less cartilage. The cartilage eroding over time is what could eventually lead to a knee replacement. There are other more risky procedures that I could have considered, such as injections, but Dr. H and I were in agreement that I was too young to worry about those types of operations, and that simply trimming the damaged cartilage was my best bet.

Even if I wanted to have the surgery right away, my knee was too swollen to operate on. Dr. H recommended that I start physical therapy initially to help get the swelling down, then to build up as much strength as possible prior to surgery. He wrote me a prescription, and I would begin my PT that weekend.

April 18th, 2015

I decided to make the trek downtown to Tribeca, where Fusion Physical Therapy and Sports Performance had recently opened their new facility. Fusion sponsors my rugby club, and because I had experience working with them I knew they were knowledgeable about sports injuries. This place would be my second home for the next year, and looking back on my journey I can say with certainty that the entire staff at Fusion played an integral part in my recovery and overall well-being.

I took an Uber down to their facility, and was excited yet nervous to start this process. I had never done any official PT before, so I had no idea what to expect from this initial assessment. I met with Brian, who would be the physical therapist conducting my assessment. After recapping my injury history, he explained that the first step was the get the swelling down. Regaining flexibility and range of motion was next, followed by strengthening the muscles around the knee as much as possible prior to surgery, specifically the VMO (Vastus Medialis Oblique). The VMO is a muscle that is part of your quadriceps, and is one of the most important muscles aiding proper patella tracking, helping to ensure your knee is aligned.

To reduce the swelling, a combination of manual massaging and icing would be repeated during every PT session. Electrical stimulation units would also be used to help increase contractions and make the muscles around the knee fire back into action. It was important to increase strength and flexibility throughout the entire leg, especially the hips. I was given a series of stretches and strength exercises to perform daily. My first round of exercises included: isometric quadriceps contractions, heel slides, a series of leg raises (supine straight leg raise, side lying adduction, side lying abduction, prone extension/straight leg raise). As I progressed I would incorporate standing calf raises on body weight shifts, where I would gradually get my body used to putting pressure on both feet.

The folks at Fusion also provided me with a piece of advice that would alter the way I approached my surgery. I knew I wanted to get at least one more opinion from another orthopedic surgeon, but wasn’t sure which hospital or doctor to consult. Fusion immediately recommended Dr. A at the Hospital for Special Surgery. Supposedly he was an extremely accomplished doctor at the cutting edge of the most advanced procedures related to sports performance. I was sold, and immediately booked an appointment to see Dr. A.

May 1st, 2015

Walking into Hospital for Special Surgery was unlike any medical office I had been to before. Their Upper East Side facility is massive, and outside the hospital their slogan, “Where the world comes to get back in the game”, is plastered across a walkway connecting two of their buildings. Once inside the decor is clean and modern, including everything from the gym and cafeteria on the first floor to the elevators and silhouettes of people acting out various sporting poses. While Lenox Hill Hospital had a noticeably diverse clientele, I could feel HSS was a place for athletes. It was as if this is where Ivan Drago came to train to fight Rocky in Rocky IV. I don’t mean to imply that Manhattan Orthopedic and Lenox Hill Hospital are below average – they have world-class doctors, clean facilities and a friendly staff – but this was how strong of an impression HSS had on me. Of course they also treated a wide range of patients for a variety of reasons, but it was very clear this place specialized in sports-related surgeries. There were so many patients and so many doctors on staff, they did a nice job of getting everyone in and out in a relatively short period of time. I didn’t initially view the high volume of patients as a good thing, but it would be something I adjusted to later on in the process.

A physicians assistant brought me from the general waiting room to a private patient room. I sat there for only a few minutes, but it felt like an eternity. A young doctor walked in and introduced himself as Dr. B. He explained that he would be assisting Dr. A that day. He was friendly and receptive, which made me feel at ease. I told him the history of my injury while he examined my knee, and he seemed to generally agree with the previous two doctors’ assessment. Then he disappeared for another few minutes. When the doors opened again Dr. B doctor appeared, this time with Dr. A. His introduction was a crisp handshake with a matter-of-fact look, and he immediately began examining my knee. I rushed through the history of how my injury occurred again, while the first doctor was simultaneously whispering his thoughts to Dr. A. After a few short minutes of range of motion and muscle contraction tests, he gave me his prognosis.

To confirm what the previous two doctors had said, he concluded I had definitely tore my MPFL, and the cartilage damage confirmed that this had been happening for some time. The official diagnosis was the following:

MPFL rupture, medial patellar osteochondral fragment, and rupture of the medial retinaculum.

For simplicity I have always explained my injury as a torn MPFL, but there was a lot going on in my knee due to the years of repeated subluxations.

Dr. A recommended a full reconstruction, but with an autograft taken from my hamstring to repair the torn ligament. In addition, he suggested a procedure called a lateral release to loosen the lateral retinaculum. This would supposedly prevent the any tugging that would pull the knee laterally. There was also one more kicker. Dr. A wanted me to undergo an additional exam called a CT scan. This would pick up on different images that an MRI does not cover, and would determine if I needed an operation called a tibial tubercle osteotomy. This procure involves cutting and moving a bone, the tibial tubercle, which is the bump of bone where the patellar tendon goes into the shinbone. The CT scan would reveal how many degrees off-center the bone was, and if the results revealed that it the TT-TG (tibial tubercle-trochlear groove) distance was more than 20mm, Dr. A would recommend this procedure be done in addition to the MPFL reconstruction. All of this was said in the same matter-of-fact manner that he introduced himself to me with. After about 7 minutes with Dr. A, he shook my hand again and left the room.

I sat there with my head spinning, and all of a sudden I was very nervous. Not only had I not considered the hamstring autograft procedure, but the idea of cutting and moving a bone in my shin had never crossed my mind. I knew that Dr. A had a reputation as an industry leader and performed the most cutting-edge procedures, but this seemed a bit much to me. A ton of additional questions arose, and I knew I would need them to be answered before undergoing any kind of operation.

As I left the office my mindset changed a bit, and I started to feel a little relieved in a way. I came to terms with scheduling the CT scan, as getting that over with would be the only way to know for sure how messed up my knee really was. It also helped that throughout Dr. A’s office and the halls of the second floor were covered with autographed pictures and jerseys from professional athletes. Players from the NBA, NFL, Olympic teams – you name a sport, it was represented. As I watched Iman Shumpert play for the Cleveland Cavaliers in the NBA playoffs later that night, I remember thinking how cool it was that the doctor who helped him get back on the court would possibly be the person helping me get over my own setback. This wasn’t a deciding factor for me at all, but it definitely made a positive impression on me subconsciously.

May 16th, 2015

A month and a half from my injury and about a month after starting physical therapy, I finally ditched the crutches. It couldn’t have come at a better time, as I was in Madison, Wisconsin for my sister Eileen’s college graduation. I had brought one crutch with me as a precaution, but I was able to move around on my own all weekend, albeit gingerly.

This weekend was a happy occasion and a reason for my entire family to celebrate, but it also provided me with an opportunity to reflect and get my mind right for a pending decision. Knee issues have become somewhat of a hereditary plague among my siblings – my brother Bryan had recently overcome a complicated and debilitating knee issue, and my sister was currently going through something similar. It was safe to say I would have a good audience to bounce my thoughts off regarding my own woes.

20150516_235008
Evidence of good times in Madison, WI

Aside from finally being able to walk on both legs without assistance, I had other good news to share. The CT scan results were in, and my TT-TG distance came in at 14mm. This meant that I was not a candidate to undergo an osteotomy, which was a massive relief for me.

The second time I met with Dr. A, he greeted me almost with a dap, a contrast from the stern handshake from our first meeting. Our conversation was brief and to the point, but he made sure to answer all of my questions. I could tell he cared about my well-being, and his persona radiated with confidence and experience.

Going on several rounds of doctors visits with multiple surgeons helped me come to an important realization – it is essential to ask the right questions and not be shy about clarifying what you don’t understand. It is your body we are talking about, no one else’s. For the most part the surgeon will tell you what he will be performing and provide an estimated recovery time, but it is up to you as the patient to ask for further explanation. Do your own homework – come prepared to each doctors visit with specific questions you want answered, and don’t leave until you are comfortable and fully understand the answer. The physicians assistants for both Dr. H and Dr. A were extremely helpful, and I called each of them half a dozen times to ask questions and get clarity on things I didn’t understand. As medical professionals who are in the room helping to perform surgeries every day, they are a valuable resource. Plus, they are often more accessible via phone then the surgeons themselves. All of this helped me tremendously, and it saved me from a near disaster the day I went in for my operation, but you’ll have to wait till part III of the saga to hear about that.

With the worry of a more complicated procedure alleviated and my physical therapy working wonders, it was now time for me to seriously consider which type of operation I would undergo – autograft or allograft.

Dr. A suggested the autograft for several reasons. Replacing a damaged ligament with your own body part, especially at 27, was usually the best option. I was young enough to recover from it, and the damage to my hamstring would be minimal. Although the site where they extracted the graft would need to heal, the reconstructed ligament would be stronger and potentially last longer than an allograft from a cadaver. If I was older or led a less active lifestyle he might recommend an allograft, but for an athlete in my situation he said it was fairly common to undergo and successfully recover from this type of procedure. He did say that he was comfortable performing either operation, but that it is ultimately up to the patient and what they are most comfortable with that determines what he does. It was his job to provide me with all of the information, and mine to decide what is best for my body.

Although I had asked the doctors all my questions and was starting to understand a lot more about the different procedures their implications, one can start to see the quandary I was in. I had spoken with three doctors, two of which I was considering for my operation. Each of them had years of experience dealing with athletes and were well-respected within their field. However they were giving me two different opinions on how I should repair my knee. I fully understood that anytime you cut open your knee it is no joke, which is why I did not take this decision lightly. I needed more information, so I started to solicit feedback anyone and anybody who could listen for advice.

It wasn’t just that weekend in Madison with my family. I would talk to friends, cabbies, co-workers, former coaches, even random people on the bus. Here are some sample conversations:

The orthopedic surgeon I saw in Connecticut from a couple of years ago – As someone who had previously examined my knee he understood my predicament, and gave me his versions of the pros and cons. He said Dr. H was well-respected, and if I recall correctly he recommended going with the allograft.

The brother of my cousin’s husband – He is a renown orthopedic surgeon in his own right, but he does not normally work with athletes. It was great to hear his perspective. Since the MPFL was a tiny ligament of the VMO was a large muscle, he recommended that I hold off on surgery and perform really aggressive physical therapy on my VMO. If the subluxation occurred again, then consider surgery. I thought his was sound logic, however this was the last time for me. I knew I had to get surgery.

Amber, Dr. A’s PA –  We had one 30 minute conversation that went a long way in helping me ultimately decide which way I should go. I asked Amber exactly what they would be doing to my knee if I elected the autograft procedure, how the pain differed for each procedure, and how it effected recovery time and performance. This is oversimplifying her response, but she said that when they harvest hamstring grafts for ACL surgeries, they usually take two out of the four available, but for the MPFL that only need one. Also I shouldn’t really worry about hamstring pain because they would be drilling into my kneecap to repair the ligament anyway, so that is where most of the pain and discomfort would be. That actually made sense to me, and instead of worrying about the pain in my kneecap it made me more at ease with the autograft option.

Fusion, various physical therapists and trainers – They gave me great advice regarding recovery time and overall sports performance. In most of their opinions the hamstring autograft wasn’t a big deal at all, and the muscle was so big it would heal itself to the point where I would barely notice any difference. The consensus was that it would take about a year from surgery for me to feel 100% again, which was also what Dr. A had said. The success rate for either type of operation was good, but for my case that it was clear the autograft was their choice.

Advice from current and former rugby teammates –  Aside from the surgeons themselves, the most practical advice I received came from my friends who had gone through knee surgery themselves. At the same time this was also the most frustrating. Most of my friends had been through ACL surgeries, which is a more recognizable injury. While I learned that the ACL and MPFL require similar recovery times, they are different body parts with their own intricate properties, and require different surgical techniques and slightly different approaches to physical therapy. On the positive side, I got to hear about various types of grafts that were used, what went into the decision-making process, and how different types of surgeries impacted each individual. I also heard that Dr. A had performed numerous operations for older members of my rugby club, with mostly great results.

The downside was at times my friends would compare my injury to theirs, or provide innocent pieces of advice as though it were definitive fact, although it never actually occurred for me. I would also hear stories about studies done for professional rugby players in England, and how results showed you should never take autografts from your hamstring, as the ability to stop and start explosively is impacted, decreasing optimal athletic performance. This logic made sense and worried me at first, but the more I thought about it the less I seemed to care. I wasn’t a professional rugby player, nor was a I a candidate for the USA World Cup team. I was starting to come to grips with the fact I would probably be out of rugby for a full year, so I might as well take my time to make the right decision, and make sure I rehab properly. Yes, my goal was to get back to an active lifestyle which included playing rugby, but the long-term goal was to be active the rest of my life. Which operation would give me the most peace-of-mind long-term? This was the main factor in how I would go about making my decision.

The best piece of advice I received, from several people, to whom I will be forever grateful – Do all the research you can, talk to as many people about this as you want, but realize at the end of the decision rests in your hands. Make the decision that YOU are comfortable with, and don’t turn back. Once you decide, go forward with a full head of steam, and don’t listen to whatever anyone else says past that point.

It took a couple of months for me to fully grasp this concept, but by early June I had read enough articles and questioned enough people. Despite my initial reservations, I chose to go with the autograft procedure because I felt it would provide me with the healthy knee in the long run. I called up HSS and Dr. A’s office and made an appointment for July 8th to repair my MPFL with an autograft from my hamstring. The decision had been made.

– John Tublin

  • Feel free to contact me if you would like more detail on the hospitals and doctors I visited. Actually, feel free to contact me about anything. I’m all ears.
  • Also, here are a few example resource I used to research this injury. They include Wikipedia posts, WebMD definitions, and even a blog post that a father wrote about his daughter going through the same decision-making process.

http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=f1a75188-3098-4710-a0d5-82a369603ea6

https://en.wikipedia.org/wiki/Medial_patellofemoral_ligament

http://soccerknee.blogspot.com/2010/03/mpfl-surgery.html

http://www.webmd.com/pain-management/knee-pain/tc/lateral-release-surgery-for-patellar-tracking-disorder-topic-overview

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